Parkland Memorial Hospital has just passed the halfway mark in its 18-month, do-or-die probation. And signs of the continuing patient safety crisis abound.

Patient demand is rising at a particularly difficult time, officials say. Nearly 1 in 6 jobs is vacant at the Dallas County public hospital. Many remaining employees are demoralized. Many are also temporary hires — an impediment to essential permanent change, according to the latest report from federal safety monitors.

Fatigue, the monitors say, is “setting in among all key stakeholders.”

The report credits Parkland with completing about 80 percent of required tasks. But finishing a project is not the same as creating “a sustainable practice,” it cautions.

“Continued adverse patient safety and quality of care issues in May, June and July suggest that not all of the efforts in the CAP are resulting in an ultimately safer and higher-quality patient experience,” the report says, referring to the corrective action plan that the federal government mandated in return for continued Medicare and Medicaid funding to Parkland.

In several key areas — including some where failures put Parkland under the rare and intense form of monitoring — “measures are in fact trending downward or backward.”

For example, slightly more than 10 percent of July’s emergency room patients gave up and left without seeing a doctor. That’s the highest rate since the monitors started measuring in March.

In the so-called women’s ER, which deals with urgent pregnancy-related problems, nearly 16 percent of patients left without receiving treatment. Again, that’s the worst month so far.

Also headed in the wrong direction were sanitation and infection-control measurements, such as how long cleaning crews take to prepare patient rooms. Delays contribute to ER backups.

Violations of hand-washing rules spiked to nearly 1,000 in July, up 32 percent from June. The surgical-site infection rate more than doubled.

“Audits indicated some additional problems with general cleanliness in the facility and improperly stored needles and sharps,” says the report by consulting firm Alvarez & Marsal.

Parkland has since installed hundreds more hand-sanitizer dispensers to facilitate compliance with hygiene demands, officials say.

Supervision issues

The report describes ongoing problems with oversight of doctors in residency training, as well as “significant progress” in resolving them.

In one test, monitors checked whether UT Southwestern Medical Center supervisors were notified before residents performed unspecified bedside procedures. About 1 in 5 cases lacked documentation of this last month.

An existing task force designed to fix such failings “approved a new policy on medical procedures and events that require advance approval” by UTSW faculty “or direct supervision,” the report says. “Significant work was done to ensure residents are qualified to perform high-risk procedures.”

Ron Laxton, the Parkland executive responsible for implementing the corrective action plan, gave hospital board members an upbeat assessment Tuesday of supervision issues and other matters.

“I see the oversight occurring,” he said.

David Wright, deputy regional administrator for U.S. Centers for Medicare & Medicaid Services, said he hopes a “safety culture” is emerging at Parkland. But he said some of the report’s findings “can be disturbing.”

Wright’s agency, widely known as CMS, forced Parkland to hire the monitors last fall after a Dallas Morning News investigation revealed widespread problems in resident supervision and patient harm. The hospital, which gets about a third of its operating budget from Dallas County taxpayers, has until April to make systemic improvements. Failure would lead to a crippling cutoff of Medicare-Medicaid funds.

“You all have uncovered some pretty ugly truths about Parkland,” hospital board chairwoman Debbie Branson recently told The News. But she argued that it is now “making some pretty revolutionary changes.”

Branson acknowledged concern about the continuing breakdowns and added: “We recognize that we have months and months of hard work ahead of us. We’re going to continue the focus, continue the work and get it done.”

Monitoring team leader Peter Urbanowicz noted that even before the recent patient increases, Parkland was a large and “very, very busy place,” with one of the nation’s busiest birth units. He said that 62 babies were born there on one recent day — about twice the hospital’s average — and that the emergency room had been unusually crowded in August.

The corrective action plan requires several simultaneous projects, each of which “would be a very complicated project for any hospital,” Urbanowicz said. “We’re trying to do about a dozen of them all at the same time.”

Wright, Branson and the monitors all hailed Parkland’s recent executive leadership shake-ups. Some changes were announced last month, including the appointment of Parkland’s fourth psychiatric services boss in little more than a year. This month came word that the interim chief executive — Dr. Thomas Royer, whom the monitors had repeatedly criticized — was being replaced.

It “shows they’re willing to take the necessary steps,” Wright said in praising Parkland’s board.

Branson said the new interim CEO, Bob Smith, has much-needed experience turning around troubled institutions. He comes with some baggage, however.

Smith retired late last year from Tenet Healthcare, a large for-profit chain of hospitals. As one of its regional administrators, he oversaw a New Orleans facility where 45 patients were found dead after Hurricane Katrina hit in 2005. Tenet paid $25 million to settle accusations of emergency preparedness failures while denying wrongdoing.

Last fall, CMS cited another Tenet hospital that Smith oversaw, Lake Pointe Medical Center in Rowlett, for violating three patients’ rights to emergency care. Parkland’s repeated violations of this law were a key reason CMS installed the monitors there.

Federal records say that Lake Pointe, like Parkland, failed “to provide an appropriate medical screening examination to determine whether an emergency medical condition existed.” Two cases cited involved pregnant women in pain who were sent from the ER to the birth unit and then discharged after not going into labor. The records don’t say whether the women suffered harm. Lake Pointe says it has added required competency training for nurses who do medical screenings.

The third citation involved an ill elderly woman who needed dialysis and was at a hospital that said it didn’t have the needed equipment. Lake Pointe did — but it refused to accept her as a transfer patient and didn’t document a reason. (It has since argued that the hospital seeking the transfer had the capacity to treat the patient.)

The Rowlett hospital promptly corrected its problems, officials say. Still, CMS has referred the matter to the U.S. health department’s inspector general for further investigation and a possible fine.

Smith, who will be paid $60,000 a month, called Parkland a “professional challenge” that is luring him out of retirement next month.

“This hospital has to survive,” he said. “If it were, theoretically, to close or limit services beginning sometime in the near future, I don’t know if there’s a hospital or hospital system in town that could take the place of what Parkland does and do it well and do it quickly.”

Neither Smith nor Royer attended Tuesday’s board meeting. But Royer did leave behind a final report showing the decline in employee morale. He cited a recent survey showing that only about a quarter of the staff is “actively engaged” — a reference to workers’ commitment and enthusiasm.

Royer’s parting words

The departing CEO’s report also included an article from Physician Executive Journal titled “Am I Demoralizing My Staff?” It lists 10 questions for health care managers to ask “to ensure they are leading and not bringing down their staff,” Royer wrote.

Low levels of nurse engagement are the top predictor of high mortality and complication rates at hospitals, according to a 2005 analysis by the Gallup research organization.

Nurses have been leaving Parkland in droves. About 400 of 3,100 nursing jobs are open, according to hospital officials.

begerton@dallasnews.com;

mmoffeit@dallasnews.com

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